Perry County Homeschool Hybrid
2024-2025
Program Application Form
Thank you for your interest in our Homeschool Hybrid Program! 📚 Please note that completing this application form does not guarantee enrollment. Priority consideration will be given to students who have not yet mastered foundational literacy and math skills. Applications will be accepted through May 15th, with acceptance announcements by May 20th. A $200 non-refundable enrollment fee is required upon acceptance to secure your child's spot. Thank you for considering our program! 💼
Student #1 Name
*
First Name
Last Name
Student #1 Nickname
Preferred Nickname
Student # 1 Birthday
*
 -
Month
 -
Day
Year
DOB
Student # 1 Does your child have a diagnosed or suspected learning or developmental disability? If yes, please specify.
*
Student #1 Previous School Experience
*
Previous School Experience
Student #2 Name
First Name
Last Name
Student #2 Nickname
Preferred Nickname
Student # 2 Birthday
 -
Month
 -
Day
Year
DOB
Student # 2 Does your child have a diagnosed or suspected learning or developmental disability? If yes, please specify.
Student #2 Previous School Experience
Previous School Experience
Guardian #1 Name
*
First Name
Last Name
Guardian #1 Phone Number
*
Please enter a valid phone number.
Guardian # 1 Email
*
Email: example@example.com
Guardian # 1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian #2 Name
First Name
Last Name
Guardian #2 Phone Number
Please enter a valid phone number.
Guardian # 2 Email
Email: example@example.com
What type of technology does your child have access to at home?
*
Laptop
Chromebook
iPad
Cell Phone
Other
N/A
If applicable, can your child bring the above technology to scheduled classes?
Please Select
Yes
No
Occasionally
Anything else we should know about your child/ren?
*
Likes/Dislikes, Strengths/Weaknesses, Personality, Academic Levels, Behavior Concerns, etc.
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